Summary Report for FSPSAs Ending During the Report Period Center: 05
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 10/01/08 and 12/31/08 Date of Report: 02-16-09 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Screening, Eval, and Assessment, Class # 02
AUDE -AUDE UNSPECIFIED AUDE SERVICES 4 4 2.98 $178.67 $60.00
EXIT -EXIT TRANSITION ASSESSMENT 14 18 30.00 $1500.00 $50.00
IPDEF -IPDEF_NM F/U PSYCH & DEV EVAL BY NON-MED PRO 1 1 1.00 $55.50 $55.50
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 3 3 5.00 $375.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 1 1 2.00 $150.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 3 3 5.00 $375.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 3 3 5.00 $277.50 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 7 7 8.00 $444.00 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 41 41 71.00 $5325.00 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 11 11 16.00 $1200.00 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 22 22 35.00 $2625.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 30 30 60.00 $3330.00 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 24 24 34.00 $2550.00 $75.00
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 19 20 20.00 $970.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 9 9 9.00 $436.50 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 12 13 13.00 $630.50 $48.50
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Subtotal (Total Children Is Unduplicated) 113 210 316.98 $20422.67 $64.43
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 13 13 18.00 $27000.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 2 2 6.13 $306.43 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 108 236 471.00 $23550.00 $50.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 112 118 234.57 $11728.57 $50.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 61 66 132.00 $6600.00 $50.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 65 68 136.00 $6800.00 $50.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 84 87 174.00 $8700.00 $50.00
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 2 2 1.67 $41.67 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 9 9 15.93 $398.34 $25.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 7 7 55.57 $2778.57 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 96 105 639.32 $31966.22 $50.00
INTR -INTR INTERPRETER 4 4 7.00 $350.00 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 37 40 193.75 $13151.95 $67.88
PHY -97110 PT SESSION BY LICENSED PT 55 56 180.97 $12284.35 $67.88
SENS -HA_INS SENSORY AID INSURANCE PER EAR 1 1 0.21 $13.72 $65.00
SENS -V5264 EARMOLD 2 2 2.42 $45.34 $18.72
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 68 69 312.09 $21184.38 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 2 2 10.79 $142.37 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 1 1 2.00 $200.00 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 155 204 424.43 $212.21 $0.50
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 1 1 2.57 $128.57 $50.00
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Subtotal (Total Children Is Unduplicated) 179 1093 3020.42 $167582.68 $55.48
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Total 1303 3337.40 $188005.35 $56.33
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Number of Children (Unduplicated) With at Least One Authorization 194